Have you ever heard that gentle whisper in your head, when you walk into the operatory and realize that your patient is high? Maybe it’s the alcohol that you smell on your patient’s breath or the constricted pupils suggestive of opioid abuse or even the sweaty forehead and jerky movements that occur with methamphetamine abuse. Despite these tell-tale clues and even despite the oath to which we all vowed to adhere, “Do no harm,” that gentle voice whispers us into submission.
It might be the whisper that tells us “You’re reading the clues wrong” or “It probably was just a little bit of alcohol” or “Just treat him quickly and get him out of the office” or even “He’ll be OK if you use an anesthetic without epinephrine.” These gentle whispers convince us, even coax us, to proceed with care, ignore the clues and avoid, at all costs, discussing substance abuse with our patients. What is it about addiction that creates silence?
Can we DeW better for our patients?
The silence of addiction stems from general misconceptions about what addiction is, who addiction affects and whether we have patients in our practices who are addicted. Addiction is a chronic, relapsing brain disorder affecting more than 23.5 million Americans or roughly 1 out of every 10 of us! It is a disease with genetic, environmental and biologic factors that creates permanent neurochemical changes. These changes alter the individual’s responses to rewards, stress, judgment and self-control.(1)
Addiction is not a “bad choice” or a “character flaw” but is instead a disease that is more common than cancer.(2) Anyone can become addicted regardless of their age, gender, race, culture, income, educational attainment or family status! This means that we all have a shared vulnerability for addiction. Any one of us can become addicted, which is a disturbing reality. Equally disturbing is the reality that we all know someone who is addicted (remember, 1 out of every 10 Americans are addicted). It might be a family member, a friend, a colleague or one of our patients.
It is this vulnerability and even connection to addiction that creates silence when we encounter it in our practices. It might be silence due to the pain of having a loved one addicted, which has created emotional exhaustion and a desire to deny its existence in our practices. It might be silence due to disappointments experienced when a friend relapses, making it a disappointment we wish to avoid at work. It might even be silence due to feelings of helplessness and not knowing how to help a patient who is addicted. These emotional reactions create silence when an addicted patient walks into our practice.
Can we DeW better for our patients?
What further strengthens the silence is our uncertainty about how our patients will react if we discuss the smell of alcohol on their breath, the track marks on their arms or the “meth mouth” on their teeth. Will they get angry, feel judged or even leave a negative Yelp review? Can we DeW better for our patients?
The answer is “Yes!”
Talking to your patients about addiction does not need to be difficult. It just takes a bit of practice, a few tips and clear goals. The goals of these discussions are to obtain information that allows you to “do no harm,” “do good” and “be ethical.” The principle of non-maleficence means abstaining from doing harm.3 We want to dispel those gentle whispers in our head so that we do not ignore the clues of addiction in our patients and possibly create harmful and life-threatening situations. Discussing our concerns allows us to re-schedule a patient who is intoxicated, avoid a fatal anesthetic/drug interaction and prescribe non-addictive medications to these patients.
The principle of beneficence means that these conversations can assist us in developing treatment plans that can be successful for patients with substance use disorders. We can incorporate into our treatment plans topical fluorides, glass ionomer restoratives, salivary substitutes and frequent recall visits to combat the high caries rates, xerostomia, salivary acidity and poor oral hygiene that occurs with substance abuse. These conversations can interrupt the cycle of poor oral health and help us deliver high-quality and sustainable oral care to our patients. Finally, these conversations allow us to uphold our ethical responsibility of directing our patients to recovery and rehabilitative resources in our communities. Having these goals in mind allows us to DeW better for our patients.
The challenge, of course, is to know what to say and how to say it!
We do not want our emotions of denial, shame or helplessness to hinder our conversations; and we also do not want our patients to feel judged, accused or even criticized. This requires that we first manage our own emotional reactions to addiction and address addiction with objectivity and neutrality. I imagine that when you ask a patient if he has high blood pressure that this conversation does not create any angst for you. When you talk to a patient about addiction, you need to maintain that same level of objectivity because addiction, like hypertension, is a disease.
Remembering the disease model of addiction allows you to approach the conversation with objectivity and concern and not dread and denial. The next step is to manage your patient’s perception of why you are asking these questions. It is important to share with your patient your goals of doing no harm, doing good and being helpful. This can reassure the patient and re-frame the conversation from one that could be viewed as accusatory to one that is viewed as helpful as you share your desire to help your patient achieve a beautiful and healthy smile.
Some phrases that I have found helpful are:
- “You indicated on the health history form that you have had a history of substance abuse. Can you tell me a little more about that?”
- “I am concerned about you, and I smell alcohol on your breath. Are you OK? Can you tell me what is going on?”
- Can you tell me about your methamphetamine use this week? In what ways are you concerned about your drug use?
- What changes, if any, have you noticed in your mouth since using drugs?
These questions are open-ended and require that the patient respond with an explanation or narrative. Open-ended questions allow you to understand the patient’s motivations, actions and challenges and allow the patient to feel understood and heard. Closed-ended questions, on the other hand, should be avoided. They force the patient to reply with a yes or no response and can make the patient feel judged, accused and defensive. Having neutral and positive conversations with our patients allow us to DeW better.
Talking to my patients about substance abuse has ended my own silence about the topic.
It has stopped those gentle whispers in my head and prevented me from ignoring important clues or proceeding with careless and potentially fatal treatment. These conversations also gave my patients the opportunity to share their challenges, hopes and dreams with me. What they shared with me at times was heartbreaking and at other times inspiring. I remember when a patient told me that he had been addicted to methamphetamine since the age of 5 as well as the patient who cried in the dental chair realizing her parents’ worries and anguish.
But I also remember the time when I high-fived my patient who was celebrating her 30th day of sobriety. Stopping the silence has allowed me to be a better dentist to my patients and fully realize my professional responsibilities of non-maleficence, beneficence and referral. I also realized that when I stopped my silence, I also stopped my patients’ silence! Let’s all start DeWing Better!
- National Institute on Drug Abuse. Drugs, brains, and behavior: The science of addiction. www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction. Updated September 2018. Accessed: 2020-06-09.
- Smith F. How science is unlocking the secrets of addiction. National Geographic 2017: 232(3).
- Wikipedia contributors. Primum non nocere. https://en.wikipedia.org/w/index.php?title=Primum_non_nocere&oldid=953382803. Updated April 2020. Accessed: 2020-06-09.